Medical Management of Pediatric Sleep Apnea and TMD in Your Dental Office: A Beginner’s Guide

Sleep apnea is a growing problem for America’s children and teenagers.  Researchers from the Cleveland Clinic have suggested that between 1% and 10% of US pediatric patients suffer from obstructive sleep apnea (OSA), with devastating results. Sleep apnea impacts children’s endocrine systems, their growth, their behavior, their ability to learn, and their ability to resist disease.  It is more common in children who suffer from obesity and children under the age of 9, but children of all ages and BMIs are at risk.  Researchers have also discovered that untreated OSA can lead to TMD in up to 73% of patients with OSA. 

Often, general practitioners lack the oral-facial medical experience to treat these conditions through non-surgical means. However, many dental offices, especially those who have embraced the dental wellness center model, are well equipped to diagnose and treat these disorders. By identifying children with risk factors, evaluating them, diagnosing OSA and TMD, and providing appliances to treat it, your office can make great strides towards improving the health, wellness, and life outcomes of your pediatric patients – and in many cases medical insurance will cover these exams and appliances, if you perform the correct evaluations and use the correct diagnostic codes.

Screening for Sleep Apnea in Pediatric Patients

Before screening a pediatric patient for sleep apnea, ask parents for a list of all current medications and the contact information for any doctors or therapists involved in the treatment of the child. This is very important since pediatric sleep apnea is often misdiagnosed as ADHD, since poor sleep severely impacts a child’s ability to pay attention and exercise self-control.

Use the following questions to pre-screen for OSA risk factors in your pediatric patients.

• Does the child sleepwalk?
• Does the child urinate in their sleep?
• Does the child sleep in class?
• Does the child act out in class or at home?
• Does the child tend to breathe with their mouth open?
• Does the child have breathing pauses during sleep?
• Does the child experience daytime sleepiness?
• Does the child have difficulty with concentration?
• Does the child have a poor attention span?
• Does the child have behavioral issues?
• Does the child show poor performance at school?
• Does the child wet their bed?

If a patient displays any of these risk factors, you should administer the Orthodontic Service Salzmann Evaluation Index.  This evaluation is essential if you plan to bill insurance for any treatments for OSA or TMD.

Documentation for Insurance

Insurers require specific forms of documentation and imaging before they will reimburse for appliances that treat pediatric OSA or TMD.  In addition to the Orthodontic Service Salzmann evaluation index, you’ll need to provide detailed notes about the objectives for any treatment or testing.

These notes should include:

• A list of the symptoms reported by the guardian and those observed in office
• References to any comorbidities that have been found to cause or be caused by OSA (for instance: ADHD, cardiac issues, obesity, diabetes, daytime sleepiness)
• The type of sleep study ordered (include relevant codes) and the reason for ordering the test
• The Current treatment plan for the patient
• The patient’s history of past treatments both for the sleep issue and any comorbidities
• If a CPAP has been tried, a notation of when and why its use failed
• A copy of results from the sleep study
• A copy of the questionnaire about sleep habits and the Salzmann test (Must score at least 42 points)
• Written reports from the pediatrician, including letters of support for this treatment option. All of the child’s doctors and therapists must be on-board with this treatment option in order for insurance to pay.

Some of these requirements may seem repetitive or redundant. However, when you’re dealing with medical insurance, it is important to make documentation as complete as possible. This will help the insurer in evaluating the claim promptly and reduce the number of hours your staff needs to spend dealing with the claim in the long-term.

Dealing with Medical Insurers

Once you’ve compiled the documentation, you’re ready to submit the claim. Each insurer has different requirements for the treatment of sleep apnea in children, what constitutes medical necessity and how to determine the severity of a given case. You should refer to these portions of the policy when submitting your claim.  Remember, you are trying to make a case that a particular child’s disease and treatment should be covered by the plan.

Be prepared to receive a ‘no’ answer on your first submissions.  Insurers initially deny 61% of claims that are eventually paid. They are trying to get you to give up on the claim, but you shouldn’t take ‘no’ for an answer.

For instance, there is a high rate of comorbidity between OSA and TMD. If the insurer finds that OSA treatment is not medically necessary, you may be able to get the child appropriate treatment by submitting via the TMD route.  Reversible intra-oral appliances can be considered medical treatment for TMD when there is evidence of clinically significant masticatory impairment with documented pain and or loss of function. The child must suffer this pain for 6-8 months before the application of appliance.  You cannot reference bruxism or sports guards in the documentation, as these are considered dental, not medical, needs. All TMD treatment requires preauthorization.

Too Complicated? Get Help.

Do the procedures for medical billing for pediatric OSA appliances seem too complicated? You and your staff can learn to bill insurance and help patients avoid unnecessary surgeries. Links2Success can help your team get the education they need to work with medical insurers so that you can help these pediatric patients.